Public bathrooms become clandestine epicenter of opioid crisis

An overdose victim is revived by Cook County sheriff's officers at the Cook County courthouse in Skokie on May 2, 2018. (Cook County sheriff's office)

An overdose victim is revived by Cook County sheriff's officers at the Cook County courthouse in Skokie on May 2, 2018. (Cook County sheriff's office)

John KeilmanChicago Tribune

It was just before 2 a.m. when Catherine Altop, a 32-year-old woman with a history of drug problems, entered the bathroom at a south suburban White Castle restaurant, locked the door and injected herself with fentanyl-tainted heroin.

Hours passed. Employees knocked but received no response. They tried to unlock the door, but the key didn’t work. Finally, about 9:30 a.m., a maintenance man got inside and discovered Altop slumped on the floor, dead from an overdose.

Publicly accessible bathrooms like the one where Altop died last year have become a clandestine epicenter of the opioid crisis, serving as the setting for numerous fatal overdoses and close calls. Just this month, Cook County sheriff’s officers revived a man who allegedly overdosed in the bathroom of the Skokie courthouse, while another man died of a suspected overdose in the restroom of a Downers Grove Starbucks.

Experts say the seclusion afforded by these spaces makes them dangerous, especially as fentanyl has increased the potency of heroin to unpredictably strong levels.

“(Using drugs in public bathrooms) is a common occurrence because people want some kind of privacy to inject,” said Dan Bigg of the Chicago Recovery Alliance, a group that provides health services to drug users. “When it comes right down to it, there are few other places as private as a bathroom.”

In response, some building managers have restricted access to their bathrooms, tried design tweaks to discourage drug use or equipped their security guards with naloxone, the overdose-reversing medication.

But Chicago activists say it’s time for a bolder step — the creation of government-sanctioned facilities where users can consume drugs under medical supervision.

“The data just go on and on about the benefits of these,” said Maya Doe-Simkins, a Chicago-based public health consultant. “There’s a reduction in overdose deaths, HIV, hepatitis C, crime, discarded syringes — all of those positive outcomes. That doesn’t just benefit people who consume drugs. It benefits everybody.”

Catherine Altop, 32, died of a drug overdose, and her family included that in her obituary to try to help others.

Catherine Altop, 32, died of a drug overdose, and her family included that in her obituary to try to help others.

Invisible haven

With lockable doors and stalls that shield people from prying eyes, public bathrooms have long harbored illicit drug use. Researchers in the late 1990s examined hundreds of heroin deaths in San Francisco and discovered that 5 percent took place in restrooms.

Robert Banks, who works for a West Side needle exchange clinic run by the University of Illinois at Chicago, said public bathrooms are a convenient spot for homeless users as well as suburbanites who drive into the city for their drugs.

“It’s kind of quiet,” he said. “You can take your time. In a car, you have to look around and see if anyone’s coming. There, you can kind of relax and do it.”

But fentanyl, a powerful synthetic opioid that is now routinely mixed into heroin, has heightened the danger of that solitude. The potent mix can cause people to stop breathing within minutes, and if they’re not found promptly, death can follow.

That’s the dismal pattern that emerges from the files of the Cook County medical examiner. Though the office couldn’t provide a comprehensive tally of people who have fatally overdosed in publicly accessible bathrooms, records show it has happened in a wide variety of settings:

• Union Station

• Malcolm X College

• Oak Park Public Library

• Harold Washington Library Center

• East Garfield Park gas station

• Mariano’s grocery store

• Starbucks coffee shops

• McDonald’s, Burger King and White Castle restaurants

Brett Wolfson-Stofko, a public health researcher with the National Development and Research Institutes in New York who has examined drug use in public bathrooms, said business owners are in a tough spot. If they’re too restrictive, they risk discrimination complaints. If they turn a blind eye, bad things can happen.

“They can lose customers because of what’s happening in their bathrooms,” he said. “The staff is also at a lot of risk for needle sticks and other things. The business community is a stakeholder in all this.”

Nasr Ali, co-owner of the Chicago gas station where a 36-year-old man fatally overdosed in a portable toilet last year, said employees now give customers about three minutes before knocking on the door. If they detect signs of possible drug use, he said, they call police.

“We find that method has helped a lot,” he said. “We haven’t had another incident like that.”

Businesses also face liability concerns. After Altop died in the White Castle bathroom, her family sued the company for negligence, and in January the restaurant chain settled the case for $120,000.

Jamie Richardson, a White Castle vice president, said the restaurants are installing keypad locks on their bathroom doors; customers will have to get the code at the front counter. That will allow employees to know when someone is inside, he said, and eliminate issues with lost or defective keys.

The company has also educated its managers about overdose awareness and worked with police to keep abreast of drug problems in areas near its restaurants, he said.

“We’ve just been hyperattentive, trying to be more vigilant about keeping an eye on things,” he said. “When you’re faced with something like this and you realize what the consequences are, it raises the stakes.”

Sounding the alarm

In Boston, the public health commission has alerted business owners about the danger of overdoses.

It has handed out posters that say, “Check your restrooms: Your actions could help save a life,” and offered to train employees to use naloxone.

Devin Larkin, director of the commission’s recovery services bureau, said it’s hard to gauge the impact of the campaign, though some businesses have restocked their naloxone after using up their allotment. (Chicago’s Department of Public Health has distributed the medication in neighborhoods hit hard by opioids but hasn’t targeted businesses specifically.)

Erica Ernst, clinical director at Renaissance Social Services, said some business owners have tried to eliminate the problem by barring access to their bathrooms, but she considers that a poor solution.

“The person might go into the alley and inject,” she said. “If we think of it from a public health standpoint, they’re in a much less hygienic place. There’s a chance of them costing one of our hospitals a lot of money. And you don’t want a deceased person in your alley.”

Some have rethought the design of their restrooms. Heartland Alliance Health, which provides care to homeless people, made sure the bathroom in its new Englewood clinic has a door that the staff can easily open from the outside if someone loses consciousness inside.

Ursula Wagner, a senior mental health clinical practitioner at Heartland, said staffers knock on the door every few minutes and keep naloxone close at hand. She also lets clients know they won’t get in trouble if they overdose at the clinic, a measure intended to deepen trust.

“It is a little bit counterintuitive, but I feel people need to accept the reality we have now,” she said.

Safe consumption

Some say the best solution is to establish “safe consumption sites” — places where people can take drugs without fear of arrest, and where trained staff can revive them if they overdose. Health care and treatment services are usually also available.

Such centers already exist in Canada and some European countries, and San Francisco is poised to open the first in the U.S. later this year. New York, Seattle and Philadelphia have announced their intentions to begin similar services.

Dr. Julie Morita, Chicago’s public health commissioner, said the city is researching the risks and benefits of the concept, but even some heroin users have mixed feelings. A 48-year-old woman at the needle exchange said that while she would welcome a safe space to inject, she was wary of having the government involved.

“The idea of them being there to help you tear yourself down, that just would mess up a whole lot of stuff,” she said.

Wolfson-Stofko, though, said decades of research have clearly established the merits of well-run consumption sites.

“If (users) have a place to inject where they’ll be treated with dignity and respect, they’ll be less likely to use business bathrooms,” he said. “We can reduce the amount of public injection that’s occurring.”